# A nurse is caring for an elderly patient with a stage 3 pressure injury on the sacrum. Which nursing intervention should be the highest priority to promote healing and prevent further tissue damage?

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> subject: Adult Health

## 문제

A nurse is caring for an elderly patient with a stage 3 pressure injury on the sacrum. Which nursing intervention should be the highest priority to promote healing and prevent further tissue damage?

## 보기

1. Apply a hydrocolloid dressing and change it every 3 days as prescribed
2. Massage the surrounding skin to improve circulation every shift
3. Implement a turning schedule every 2 hours with pressure redistribution surfaces **✔ 정답**
4. Clean the wound with hydrogen peroxide twice daily as ordered

**정답: 3**

## 해설

The highest priority is implementing a turning schedule every 2 hours with pressure redistribution surfaces, as pressure relief is fundamental to prevent further tissue damage and promote healing in stage 3 pressure injuries. Other interventions like dressings or cleaning are secondary without addressing the root cause of pressure.

## 심화 해설

Understanding the Priority: Pressure Redistribution and Offloading

For an elderly patient with a stage 3 pressure injury on the sacrum, the highest priority intervention is to implement a turning schedule every 2 hours with pressure redistribution surfaces. A stage 3 injury involves full-thickness skin loss with damage to the subcutaneous tissue, meaning the primary cause—sustained pressure—must be immediately eliminated to allow healing and prevent deterioration. The foundational principle of pressure injury prevention and treatment is offloading, which mechanically reverses the pathological process of capillary occlusion and tissue ischemia.

The rationale is rooted in the physiology of pressure injury development. When external pressure exceeds capillary closing pressure (approximately 32 mm Hg), blood flow is obstructed, leading to hypoxia, anaerobic metabolism, and ultimately cell death [1]. Repositioning at regular intervals is not merely a comfort measure; it is a mechanical intervention that restores perfusion. Research quantifying pressure distribution demonstrates that even minor adjustments in bed position can significantly alter pressure peaks over bony prominences like the sacrum [1]. A quality improvement process specifically targeting sacral hospital-acquired pressure injuries (HAPIs) identified lapses in turning and repositioning as a critical factor, and correcting this through a structured schedule was central to reducing injury rates [4]. While the conventional 2-hour turning schedule has limitations and may need individualization based on tissue tolerance [2], it remains the evidence-based standard for redistributing pressure in the absence of continuous individual monitoring technology.

Analysis of Incorrect Options

-   Option 1 (Apply a hydrocolloid dressing): Dressings are an important adjunct in wound care, but they do not address the root cause. A hydrocolloid dressing provides a moist wound environment and can manage exudate, but it cannot offload pressure from the sacrum. Even advanced multilayered foam dressings, which are designed to redistribute pressure, are secondary to the mechanical act of turning . Applying a dressing without a turning schedule would be like treating the symptom while ignoring the ongoing cause of the injury.

-   Option 2 (Massage the surrounding skin): Massaging skin over a bony prominence or near a deep pressure injury is contraindicated. The tissue in a stage 3 injury is already ischemic and friable, with damaged subcutaneous structures. Massage can cause sheer and friction forces that further disrupt fragile capillaries and connective tissue, potentially extending the depth of the wound and worsening the injury. The goal is to reduce all forms of mechanical stress, not add to them.

-   Option 4 (Clean with hydrogen peroxide): Hydrogen peroxide is a cytotoxic agent. While it effervesces and mechanically debrides, it indiscriminately destroys healthy fibroblasts and granulation tissue, which are essential for healing a deep, open wound like a stage 3 pressure injury. Modern wound care standards dictate the use of biocompatible, non-cytotoxic cleansers such as normal saline. Using hydrogen peroxide would actively impede the healing process and cause further tissue damage.References (research sources)

- [1]Quantifying and Visualizing the Pressure Distribution of In-Bed Positions to Reduce Pressure Injury Risk.Research articlevan Helden TMN, Versnel SL, Arkes L, Lindhout M, Mureau MAM, van Neck JW. (2026) · DOI: 10.1097/asw.0000000000000402

- [2]Effectiveness of skin interface pressure and temperature monitoring for pressure injury prevention in paraplegic patients: a comparative study.Research articleMiao A, Lin C, Ni Y, Yin S, Lv C, Huang H, Jiang X, Zhou H. (2025) · DOI: 10.3389/fpubh.2025.1521948

- [4]Implementation of a unit-specific quality improvement process for prevention of hospital-acquired pressure injuries.Research articleKern BK. (2025) · DOI: 10.1136/bmjoq-2025-003379

## 임상 시나리오

Clinical Practice Guide: Pressure Injury Offloading

1. Pathophysiology of Pressure Injury

Pressure injuries develop when sustained external pressure exceeds **capillary closing pressure (approximately 32 mm Hg)**. This obstructs blood flow, causing tissue hypoxia, anaerobic metabolism, and ultimately cell death. Bony prominences like the sacrum are at highest risk due to concentrated pressure over a small surface area. A stage 3 injury indicates full-thickness skin loss extending into the subcutaneous tissue, making immediate pressure relief critical to halt the ischemic cascade.

2. Priority Nursing Intervention: Repositioning

The highest priority for a stage 3 sacral pressure injury is implementing a **strict turning schedule every 2 hours** combined with pressure redistribution surfaces. This mechanically reverses the pathological process by restoring perfusion to ischemic tissues. Even minor adjustments in bed position significantly alter pressure peaks over the sacrum. Quality improvement data show that lapses in turning and repositioning are a critical factor in hospital-acquired pressure injuries, and a structured schedule is central to reducing injury rates.

3. Adjunctive Wound Management

Once offloading is ensured, appropriate wound care includes using a moisture-retentive dressing such as a **hydrocolloid** to maintain a moist wound environment. However, dressing selection is secondary to pressure redistribution. **Do not massage** the surrounding skin, as this causes friction and shear on already fragile, ischemic tissue. Avoid cytotoxic agents like **hydrogen peroxide**; cleanse only with normal saline to protect granulating tissue.

4. Interprofessional Coordination

Collaborate with the wound care team and physical therapy to obtain appropriate support surfaces (e.g., high-density foam mattresses, alternating pressure overlays). Document turning schedules meticulously and educate all caregivers, including family, on the physiological rationale for repositioning to ensure adherence around the clock.

**Key Takeaway:** Offloading is the foundational intervention that addresses the root cause of pressure injuries—sustained pressure exceeding capillary closing pressure—and must be prioritized over topical wound care to promote healing and prevent deterioration.

## 핵심 개념

- **Capillary Closing Pressure** — The minimum external pressure (approximately 32 mm Hg) required to collapse capillaries, obstructing blood flow and leading to tissue ischemia.
- **Offloading** — The mechanical redistribution of pressure away from a bony prominence to restore perfusion and prevent pressure injury formation or deterioration.
- **Stage 3 Pressure Injury** — Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
- **Tissue Ischemia** — A condition of reduced blood flow and oxygen delivery to tissues, often caused by sustained external pressure, leading to anaerobic metabolism and cell death.

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